This is the final part of a Deseret News series that examines how Utahns are empowering our poor in three areas: homelessness, education and health care.

SALT LAKE — It's 8 a.m. on a freezing-cold Sunday beneath the 500 South viaduct. Under the shelter of the overpass, a line of volunteers, their breaths clearly visible in the cold air, are serving breakfast on cardboard plates to the homeless.

But not everyone's focused on the tempting aroma of the hot buttermilk pancakes and meaty gravy that's being scooped over mashed potatoes. Bob, a tall, skinny man in a tattered gray coat, is searching for the nurse who sometimes shows up. He's got a bad rash, he says, pushing up his sleeve to show a volunteer the angry red bumps from his wrist to his elbow. Sometimes the nurse gives him ointment that helps.

A few minutes later, a harried mom pushing an overstuffed stroller with a toddler sitting beside what looks like a trash bag full of clothes makes the same request. Did the nurse come?

Not today.

When you're poor and uninsured or underinsured, health care can be a vexing problem.

Last year in Utah there were 387,100 people without insurance, including 100,500 children, according to the Kaiser Family Foundation. Of those, 71 percent were in families with at least one full-time worker. Another 12 percent were in families where someone worked part-time. Most of the uninsured are poor.

And even when there's help, it may not be complete. While 10 percent of the state's population has Medicaid, there are gaps in what it covers. Many low-income folks don't qualify for Medicaid or for the Children's Health Insurance Program. Barring the ability to get health insurance through an employer or afford it on their own, they slip through some good-sized cracks when it comes to accessing medical care.

It's particularly true for poor working-age men and women, many of whom work for wages low enough they can't rise above the federal poverty guidelines. They compound the problem by putting off going to a doctor or getting screenings because they can't afford it. Some only go when they have more advanced and costly medical needs. Or they may use emergency rooms, which are a great deal more expensive than nearly any other option, as an entry point into the health care system. Some go there because the medical problem becomes a crisis, while others may not know where else to go. And if they cannot afford to pay for the care, some of the cost gets passed on to the paying customers in the form of higher costs.

Community answers

That ER utilization is one reason government agencies and health care providers support or offer health fairs and clinics in the community, from the Fourth Street Clinic to serve the homeless to the network of Community Health Centers like Midtown in Ogden and Central City in Salt Lake. A powerful line of care for the poor, they leverage local and federal money, as well as donations, and provide service based on a patient's ability to pay, using a sliding fee. But clinics can't just operate on fumes and good wishes. They must be what Intermountain Healthcare's community clinics director Terry Foust calls "financially viable" if they're to stay open. They can't just see patients who need free service, he said. There are real costs associated with stitching arms and treating disease.

School might seem a funny place to establish a medical home, but that has proven to be an effective and accessible choice for low-income inner-city residents in the neighborhoods around Rose Park and Lincoln elementary schools, where Intermountain Healthcare has done just that. A string of community and school-based clinics stretches from Logan to St. George, said Foust. There's a clinic in Dixon Middle School in Provo and they've teamed up with a community health clinic in Ogden to provide services at James Madison Elementary, which also hosts a major community-wide health screening event over a couple of days each year. In most cases, charges are based on income level.

A clinic in an alternative high school in St. George focuses on at-risk teens. The school is also home to an early Head Start program for the children of the teen parents. Such tools are, along with the education components, key to the high rate of graduation and college placement the school enjoys despite the challenges the students face.

But with numerous efforts to make care accessible and affordable for the poor, Foust said, people still fall through the cracks. Intermountain runs seven clinics statewide for low-income, homeless and uninsured patients and provides financial and volunteer support to independent medical clinics for the uninsured and medically under-served. Between them, they support a quarter-million patient visits. "We run about 92 percent uninsured. It used to be between 72 and 78 percent that had no other payment source."

The clinics focus on primary health care, flu and chronic conditions like diabetes, he said. The big change has been who needs the low- or no-cost care. "We're seeing patients who had insurance who lost a job, the under-employed and those who are working for quite a bit less. Their income has changed. And there's another group. In an attempt to not cut anyone's job, some employers cut back hours, leading to a loss of benefits. We see a lot of those."

The medical needs have become more complex, too, he said. It's more apt to be uncontrolled diabetes than a sort throat.

Monday, Derrick Joseph, 11, and Tyler Pollock, 12, waited patiently in the butterfly-themed waiting area of the Main Street Clinic, run by Salt Lake Valley Health Department, to get immunization shots that would let them go to school. They didn't know each other, but represent the spectrum local health department clinics serve: Troy Pollock said his son Tyler has good insurance. Vini Joseph said her son, Derrick, has no insurance at all yet. The boys agreed, though, that the shots didn't hurt much.

Besides providing low-cost or free vaccinations for children, public health clinics on a sliding scale also do prenatal care, women's cancer screening, testing for sexually-transmitted diseases and more.

United Way in Utah County operates a program that provides mentors to first-time moms.

"A calling"

With so many needs, it's fortunate that health care and charity have been intertwined in Utah since Mormon pioneers entered the valley. In 1868, Brigham Young, leader of The Church of Jesus Christ of Latter-day Saints, called Eliza R. Snow to help organize Relief Societies. President Henry B. Eyring, First Counselor in the First Presidency of the LDS Church, recently recounted the history in a talk: "Under the leadership of women of great vision and capacity, the Relief Society took the lead in starting charitable services which did not exist on the frontier for those in need. They created a small hospital. They supported women in going to the East to get medical training to staff it. That was the beginning of one of the great hospital systems in the United States."

He's referring to the creation of LDS Hospital and Primary Children's Medical Center, later spun off by the LDS Church into Intermountain Healthcare, which the church gave to the community several decades ago when the church stopped providing direct care, although it continues to contribute to health care projects.

"You pass the heritage along as you help others receive the gift of charity in their hearts," Eyring said. "They will then be able to pass it to others. The history of Relief Society is recorded in words and numbers, but the heritage is passed heart to heart."

Nearly a century and a half after Snow was called to organize LDS women, volunteers of all faiths play an important role in the patchwork of care. Unless they're actually medical providers, they can't provide direct care, but they help with related tasks like setting up or registering patients. "If you call any clinic number, most of us can explain what our volunteer needs are. And we often know what the others need," Foust said.

Volunteers are front and center in Provo, which solved part of its uninsured problem with the twice-a-week Volunteer Care Clinic that deals with acute medical problems that require just one to three visits. Overhead is slight because it's open Tuesday and Thursday nights in space normally used by a daytime clinic. Its supplies are basic, like paper towels and over-the-counter drugs. There are no prescription drugs.

But while cost is low, how do you put a price tag on the gift of time and skills by doctors, nurses, nurse practitioners, students, translators and greeters who just show up because they're needed? What's the going rate for a pair of strong arms to brace you when you're injured or ill and uninsured?

The clinic shares space with Mountainlands Clinic, a community health care clinic that offers acute and chronic care, as well as some dental. The building also houses Community Health Connect.

The doors to the Volunteer Care Clinic open at 5 p.m. and within an hour there are 40 to 45 people filling out paperwork and waiting for help. Patients must have an income less than 150 percent of poverty — currently $33,075 for a family of four — and no access to Medicaid or Medicare. For some, the wait will be several hours, said Stuart Collyer, co-director, a volunteer who spent 32 years as a Department of Veterans Affairs administrator and now co-directs the center with his wife, Cindy. The waiting rooms are large, with a place where children can draw or watch a video. The clinic is also exploring ways to fill the space and time by teaching families about screenings and preventive health practices, perhaps using some of the student nurse volunteers, he said.

The LDS Church provided some initial money and Collyer can call for help from LDS congregations in Provo if more volunteers are needed on a given night. United Way pays for the over-the-counter drugs that are given to the patients.

Intermountain Healthcare provides needed MRIs and ultrasounds or similar tests as needed. Many of the support volunteers, who are mostly pre-med and pre-nursing students who want experience helping real people, come from BYU Service Learning Center. Some volunteers are trained to take vital signs; others help with registration and other paperwork.

Davis County has a similar clinic. In both cases, the volunteer efforts are complemented by the logistical and in-kind support of organizations.

"Rather than expect the state or federal government to solve all the problems, they pulled together and started this. It's a small group of people that get served, but it's a gap that gets taken care of," said Collyer. "I think ultimately, significant health care problems in this country are going to be solved partially like this. For me, it's a twice-a-week reminder that there are really very giving people who, once they know there's a need, are willing to help. And it's a strong indication of how we can resolve issues in our community."

Student aid

BYU nursing students "participate pretty vigorously" at the Volunteer Care Clinic, said dean of the College of Nursing Beth Cole. They also work with community health clinics and pubic health agencies on projects like flu shot campaigns.

The program's efforts stretch well beyond campus. Cole said nursing students develop newborn kits they take to hospitals and shelters to new mothers. They screen for high blood pressure and diabetes at health fairs. They provide information about diet and nutrition, exercise and more. And nursing students will help those without resources find them.

The same is true of all the programs that teach and equip young medical practitioners, from physician's assistants to physical therapists, clear across the state.

One of the biggest challenges for the poor and uninsured is getting the medicine they need.

"It's heartbreaking when you diagnose somebody with something and they need expensive medication and can't get it," said Foust, who suggests that donating money to a voucher fund for such cases is a great way to help. Voucher programs also need volunteers to help patients fill out applications for drug company pharmacy assistance programs. At Lincoln Elementary's clinic in Provo, for example, they've processed applications for more than $240,000 in high-cost medications. When a doctor prescribes a medication that a patient will likely have trouble affording, that patient can apply for some relief from the drug company. Drug company programs commonly give income-qualified patients a 90-day supply of a medication for free.

The ability to buy many common generic medications for $4 at various pharmacies has been a boon, as well. The Information and Referral line at 211, which is run by the Utah Food Bank, is a good place for people to start if they don't know where to get help with prescription costs or health care access.

The Maliheh Free Clinic in South Salt Lake also relies on the community. Volunteer health care providers staff the clinic, which was started by and still receives support from the Semnani Foundation. Community donations help keep ongoing care flowing.

There's a compelling link between health issues and homelessness, the one often leading to the others, experts say. Families and individuals teetering on the brink of financial meltdown can be pushed over by costly medical issues. And those without homes and resources are, similarly, more vulnerable to dire medical conditions because of a lack of care.

The VA Hospital makes an extensive effort to help homeless veterans with their health care needs, said Al Hernandez, homeless coordinator. They have residential treatment programs for homeless veterans and provide transitional housing and treatment for up to two years for mental health or substance abuse issues. They also have shorter-term residential treatment programs like the Ark of Eagle Mountain.

Hernandez said every housing program the VA Hospital is involved with has a treatment/case management component. Veterans go to the VA clinics or hospital for other types of care, too.

And the volunteers who help those seeking care? Most of them are veterans, too, he said.

e-mail: lois@desnews.com